CL and Vc differ markedly between patients undergoing hemodialysis and those not undergoing hemodialysis. Dosing nomogram based on these covariate relationships may potentially help in accurate dosing of vancomycin.
A majority of HIV-infected patients at one institution had at least one drug-related problem at hospital admission. The most common problem observed among the medication orders reviewed was inappropriate dosing. The most common drug-related problems observed among patients were drug-drug interactions and incomplete antiretroviral regimens.
The purpose of this study was to determine the time required for antimicrobial stewardship (AS) activities at a small community hospital (SCH) as well as barriers to remote AS to satisfy The Joint Commission (TJC)'s AS standard. Methods: This was a prospective chart review and time study conducted in patients identified by a clinical decision support application as potential opportunities for antimicrobial therapy modification at a SCH between December 12, 2016, and March 31, 2017. Potential interventions were communicated electronically to the clinical pharmacy specialist, who would then communicate the recommendations to the patient's provider. The primary endpoint was a time study for stewardship activities. Secondary endpoints included describing barriers encountered to remote AS as well as a cost-benefit analysis of remote AS. Results: The time study revealed an average of 11 alerts per day, 9 chart reviews per day, 8 interventions per day, and 5 minutes per chart. Seven hundred twenty-four alerts were evaluated with the most common alerts constituting opportunities for deescalation (29%), targeted drugs (22%), positive blood cultures (18%), Intravenous (IV) to oral (PO) (17%), and antimicrobial renal monitoring (8%).Interventions were accepted (11%), accepted modified (6%), rejected (35%), or undetermined (48%). Barriers to implementation included workflow and indirect communication. For patients with accepted interventions, there was an average savings of $279.82 per patient in pharmacy charges. Conclusion: Through remote AS, a SCH can have an antimicrobial stewardship program that is in compliance with the basic elements of the TJC standard MM.09.01.01, performs daily chart review by an infectious diseases trained pharmacist to increase the quality of patient care, and achieves a mean savings of $279.82 in pharmacy charges and $1,126.26 in hospital charges per patient with accepted interventions.
Objective The objective of this study was to assess the relationship between antibiotic exposure and subsequent Clostridium difficile-associated diarrhea (CDAD) in hospitalized patients. Methods A retrospective, case-control study with data collected between October 1, 2005 and March 31, 2006 was conducted. Cases consisted of patients with a documented new onset of diarrhea occurring a minimum of 72 hours following admission to the hospital and accompanied by a positive C. difficile toxin A and B enzyme immunoassay. Two controls were matched to each case according to known risk factors for CDAD other than antibiotic use. A complete assessment of antibiotic use was made, including all regimens the patient received during the previous 8 weeks. The difference in antibiotic use in cases and controls was tested using the chi-square test. The association between specific antibiotic classes and subsequent CDAD was evaluated with an odds ratio. Results Prior antibiotic exposure was observed more frequently in these cases than in controls (P = 0.035). Specifically, third-generation cephalosporins were found to be significantly associated with CDAD (odds ratio, 4.64; 95% confidence interval, 1.64 to 13.14). Conclusion This study showed that prior antibiotic exposure is associated with increased incidence of subsequent CDAD. Specifically, third-generation cephalosporins were statistically associated with CDAD. Although results did not reach statistical significance, this study suggests that potential associations may exist between CDAD and prior exposure to antipseudomonal penicillins, cefepime, carbapenems, fluoroquinolones, and intravenous vancomycin.
Background: Dosing vancomycin to achieve target concentrations of 15 to 20 mg/L has been recommended for select infections. To date, few vancomycin nomograms designed to target these higher concentrations have been published, and only one has been published in North America. Based on the success of this nomogram in developing empiric vancomycin regimens that achieve higher target trough concentrations with low rates of nephrotoxicity, a vancomycin nomogram targeting concentrations of 15 to 20 mg/L was developed and implemented at Emory University Hospital and Emory University Hospital Midtown. Objective: To evaluate the impact of a vancomycin-dosing nomogram on the incidence of vancomycin-associated nephrotoxicity and the time to achieve targeted trough concentrations. Methods: A retrospective chart review of 200 patients who received vancomycin dosed to achieve target trough serum concentrations of 15 to 20 mg/L was performed. Results: After implementation of the vancomycin nomogram, no statistically significant difference in incidence of vancomycin-associated nephrotoxicity was found (14% vs 16%; P = .197). Fewer patients had an initial vancomycin trough concentration within target range (29.1% vs 21.7%; P < .001). Adherence to the nomogram was poor, with only 41% of patients being dosed per the nomogram's recommendations. Conclusion: Based on our results, implementation of a vancomycin dosing nomogram had no impact on the incidence of nephrotoxicity, and significantly fewer patients had an initial vancomycin trough within the target range of 15 to 20 mg/L. The clinical utility of a vancomycin dosing nomogram is still to be determined.
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